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Module 4 Discussion Class: Nur 504 Advanced Health Assessment

October 19, 2024

Module 4 Discussion

Class: Nur 504 Advanced Health Assessment

Throat, Respiratory & Cardiovascular Disorders

For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases.

Your case number is # 2

	Case 2
Chief Complaint (CC)	A 25-year-old Hispanic female, computer programmer presents to your clinic complaining of a 12-day history of a runny nose
Subjective	States that her symptoms began about 12 days ago. She suffers from allergies; she gets a runny nose during the springtime, pollen season. However, in the winter, her allergies are not a problem.
Objective Data
VS	(BP) 115/75, (P) 89, (RR) 16, (T) 100.4°F (38°C), O2 sat 98% on room air
General	No signs of acute distress. Patient appears mildly fatigued. She is breathing through her mouth. Breathing easily. Voice has a nasal quality to it.
HEENT	Ear canals: normal; EYES: normal; NOSE: Bilateral erythema and edema of turbinates with significant yellow drainage on the right. Nares: Obstructed air passages
Respiratory	CTA AP&L
Neck/Throat	Posterior pharynx: mildly injected, scant postnasal drainage (PND), no exudate, tonsils 1+, no cobblestoning
Heart	Regular rate and rhythm, no murmur, S3, or S4

Based on case # 2, answer the following questions:

1.
What other subjective data would you obtain?

2.
What other objective findings would you look for?

3.
What diagnostic exams do you want to order?

4.
Name 3 differential diagnoses based on this patient presenting symptoms.

5.
Give rationales for each differential diagnosis.

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